Measurement of district health system strengthening efforts for maternal and newborn health service delivery: Synchronized application of evaluation models in the West Nile region, Uganda, 2019-2021

Abstract

<title>Abstract</title> Introduction Uganda has high maternal, neonatal, and under-five mortality rates. Between 2019 and 2021, the United Nations Children’s Fund (UNICEF), in collaboration with the Ministry of Health and other partners, implemented a maternal and newborn health (MNH) quality improvement programme in the West Nile region of Uganda to improve the delivery and utilization of MNH services. This study describes the application of health system evaluation models to measure improvements in health system capacity and the quality of MNH services. Methods We designed two novel health system evaluation models—the Progression and ServQual models—which progressively measure improvements in health system capacity and quality of health services. The progression model was designed to measure changes in health system capacity using a set of indicators and benchmarks. For each health system component, the tool generates scores as follows: &gt;90% for level 4 progression (surpasses basic expectations); 70–90% for level 3 (meets basic expectations); 50-&lt;70% for level 2 (needs improvement); and &lt; 50% for level 1 progression (needs urgent attention). The quality of MNH services was measured through annual client satisfaction surveys using the ServQual model. The identified health system capacity and service quality gaps were used to inform corrective action. Results Overall, the average health system capacity scores across the 12 districts increased from 62.9% (level 2) in 2019 to 71.2% (level 3) in 2021. The capacity scores for each health system component increased: governance and leadership increased from 67.7–74.1%, health financing increased from 67.4–69.3%, access to essential medicines increased from 50.2–77.0%, the health information system increased from 71.8–74.9%, the health workforce increased from 56.8–66.9%, and MNH service delivery increased from 63.5–64.5%. Client satisfaction with the quality of MNH services increased from 26.5% in 2019 to 39.8% in 2021. Conclusion The MNH program improved health systems, contributing to efforts to reduce maternal, neonatal, and under-five mortality in the West Nile region. The evaluation models are important tools for measuring the effects of health system strengthening efforts.